If your patient population is anything like mine, then you see a lot of active drug users. My dear friend, Suzanne Carlberg-Racich, Ph.D., M.S.P.H., reminded me of my faux pas immediately after the article was published. I'd like to share the ensuing conversation with you, because it includes some very good tips.

(Dr. Carlberg-Racich has worked for the past 10 years at the Midwest AIDS Training & Education Center as a research and evaluation specialist. She has also volunteered for the past eight years as an outreach specialist and volunteer coordinator for the Chicago Recovery Alliance, which is the brain child of Dan Bigg.)

In working with HIV-positive patients who are current recreational drug users, ideally, we as providers want to move our patients/clients through behavior change and off of their drug of choice. This doesn't always work, so the next best suggestion would be to help the patients/clients prevent transmission of their HIV and/or hepatitis, and to protect them from contracting any other diseases until (if ever) we can move them through recovery.

Here is what Dr. Carlberg-Racich had to say on the issue:

Prevention is an interesting thing in that it's simple but also complicated. Working in clinical care or public health, we think that giving a simple message like, "Use condoms 100% of the time to protect yourself from HIV/STIs," or, "Use clean needles to avoid getting HIV or hepatitis," will be enough.

What we forget is that information doesn't equal behavior change. What I mean by this is, you would be hard-pressed to find a smoker who is unaware that smoking can cause lung cancer, and yet they still smoke. So clearly information is not enough!

In order to help our patients or clients really change their behaviors, we need to know the context. This means having an actual conversation in which you ask really good questions, and then you be quiet and listen to the answers -- really listen!

What does this mean? You ask some good, open-ended questions (that cannot be answered with a simple "yes" or "no"), and then your patients or clients do the work, telling you about themselves and giving you all the information you need to support positive change.

So, what do you want to know? I'm suggesting we take Norman Zinberg's wonderful "drug, set and setting" concept and expand its use to cover both drug and sex behaviors, in order to help our clients change in a manageable way.

If you aren't familiar with Zinberg, here's an overly simplistic explanation:

Drug: You need to know what drugs are being used, including the pharmacology and possible adulterants, the route of administration (smoked, injected, snorted, ingested, etc.) and the possible risks associated with that route. If we expand this to sex, you would want to know the exact sexual acts, including such details as whether your clients are the insertive or receptive partner, whether any steps are being taken to reduce risk and what they can tell you about their partners.

Set: The mindset of the user. What is your patient or client getting out of the drug use or sex? Mindset has a great deal to do with how we experience drugs or sexual behavior.

Setting: A patient or client's environment can often get in the way of being able to be safe. For example, someone who is engaging in behavior that is illegal (such as injecting drugs or selling sex) will have to work to hide his or her behavior and may have less time to negotiate safer sex with a client, or may worry about carrying sterile syringes due to fear of incarceration.

Once you know these three things, you can work with your patient or client to start reducing risks in a manageable way, according to a (gasp!) sensible harm reduction model. Let's face it, folks: Harm reduction is what works, and that's why it's recommended!

In a brief example, you might have a female client who is regularly smoking crack out of a metal pipe (made from a hardware socket) with a Chore Boy screen. She is supporting her habit by performing somewhat-public, completely unprotected oral sex on male partners who are often injection drug users. Clearly there are risks here!

You know the "drug" and the "setting," but what about the "set"? When you ask her why she started using crack, she explains that she wanted to balance the depressive moments of her bipolar disorder, which is currently not treated. Now she feels she's just hooked.

So, what to do? Just offer all the options you can think of to reduce risk, such as the following examples:

referral for treatment for her bipolar disease

flavored condoms and instructions on how to apply them with her mouth

using a glass pipe or a mouthpiece on her pipe to avoid open sores and burns

using pipe screens instead of Chore Boy to protect the mucosal membranes in the mouth

not letting her clients ejaculate in her mouth

reducing her crack use or seeking treatment

choosing a "pool" of clients who are less likely to be infected with HIV

So many options, and this list isn't even exhaustive!

You name those options and ask one simple question: "What works for you?" Then you promise to check in next time with even more questions and options.

If you want to maintain a respectful, open and nonjudgmental relationship with your patients or clients, you meet them where they are, not where you want them to be. Good luck!

Thank you, Dr. Carlberg-Racich!

Selected Resources

Midwest AIDS Training & Education Center (MATEC), one of the AIDS Education and Training Center (AETC) programs of the Ryan White CARE Act (Part F), currently supports a network of 11 regional centers (comprising more than 130 local performance sites) that conduct targeted, multi-disciplinary education and training programs for health care providers treating persons with HIV/AIDS. MATEC's Web site provides a central repository for AETC programs, contact information and training materials developed within the AETC.

Chicago Recovery Alliance (CRA) is a unique organization in that it directly involves the community of people affected by HIV and drug use in the provision of support around those issues. The CRA Web site includes information on harm reduction outreach and needle exchange, abscess identification, overdose prevention, hepatitis and better vein care, which it provides in multiple-language booklets.

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